GW1-2021-03405_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We ntractor Information: f
14.WATER ZONES
Well Contractor Name ., & fL ON
FROM TO DESCRIPTION
�' �° o t� �,Qr
L13&5 J U N X 7 2021it
NC Well Contractor Certification Number IS.iOUTER CASING for multi-cased wells OR LINER ife Geable
Miller Well Drilling ROM TO DIAMETER THICKNESS MATERIAL
Inform3t,on pro_onsiriq U ft1 46 ft. CI in. © V
Company Name ��11 .enio I
D 2 �V 16.INNER CASING OR TUBING o eofhermal closed-la
2.Well Construction Permit#: 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17:'SCREEN .
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
_!Industrial/Commercial 0Residential Water Supply(shared) I8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. ft.
Monitoring Recovery ft. 2D ft.
Injection Well:
ed
ft. ft.
_.,:Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft-
_,Geothermal(Closed Loop) Tracer 20.IDRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,gmin sin,etc.
fL /v ft. /t A
4.Date Well(s)Completed: 4- 2-21 Well ID# ft. �® ft.
5a.Well Location: ft. ft.
1 r I- FL ft.
Facility/OwnerN ��)O Facili ID#(ifapppplliica/ble) 11 ft. ft.
3�.J�SNa Name.,J �V Q_ ,l// Xft. ft.
Phy I Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iadlong is sufficient) Q`2 22.Ce t' cation �
01, D 2f� N 0 13 '9��•�W -2/
6.Is(are)the well(s) ermanent or Temporary Signature of Ccror Da e
� By signing this form,I hereby certify that the wells)was(were)constructed in accordance
�f"
7.Is this a repair to an existing well: DYes or E " with 15A NCAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under ff21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �l�J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l-or multiple wells list all depths if different(example-J a100'and 2@100') construction to the following:
10.Static water level below top of casing: / , Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"4" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tn (in 24b.For Infection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,e[c.)
Division of Water Resources,.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 V Method of test: r 24c. For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: f V 2 completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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